Basic Information
| Provider Information | |||||||||
| NPI: | 1013905769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANDERLE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SCOTT NIXON MEMORIAL DR | ||||||||
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| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309072464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207293332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 2ND ST | ||||||||
| Address2: | STE. A107 | ||||||||
| City: | NEENAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549562883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207293332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 122034 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.